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Dental Tribune Middle East & Africa Edition | 5/2016 28 GENERAL DENTISTRY Invaluable Support with a First Case By Dr. Brynja Björk Hardardóttir, Sweden A 58-year-old patient presented to the practice in March 2015 with con- cerns that her upper laterals were sticking out – something that had bothered her all her life. She was otherwise healthy with no previous medical issues or current medica- tions. A full dental assessment revealed a skeletal Class II division 2 malocclu- sion,aswellasanoverbiteandasmall overjet. The lower arch had minimal crowding which did not bother the patient. The upper right lateral had undergone endodontic treatment many years previously and it was now discoloured. Many large resto- rations were present in the molars, both composite and amalgam. Aside from minimal plaque and calculus, good oral hygiene was recorded. The upper anterior teeth showed a little mobility but no periodontal pockets weredetected. Treatment options Many years ago the patient was re- ferredtoanorthodontist,butshedid not desire fixed braces. Prosthodon- tic solutions were also discussed at thetime,whichwouldhaveincluded veneers on the upper centrals and laterals, resulting in loss of a lot of tooth substance on the laterals and an elective endodontic treatment on 22. With this in mind, the IAS Inman Aligner method was suggested as an alternative option. X-rays and photographs were taken during that appointment to ascertain suitability and no pathology or abnormalities were identified. Both the upper and lower jaws were then scanned with CAD/CAM technology and the digi- talimpressionssenttoacertifiedlab. ThelabdidtheSpacewize+™calcula- tions and it was confirmed that the case was suitable for treatment. A video demonstrating the predicted result was also provided, which made it easy for the patient to visu- alize the outcome and make an in- formeddecision. Upon her consent to proceed the treatment plan was discussed in de- tail, including frequency of appoint- ments, importance of compliance, possible speech difficulties in the be- ginning, potential bleaching, chang- ing restorations in the anterior teeth andneedforapermanentretainer. Treatment provision In May, the IAS Inman Aligner was fitted. Insertion, removal and clean- ing instructions were given and the patient was advised to wear the ap- pliance for 20 hours per day. The aligner had an expansion screw and the patient was also instructed to turnthescrewbyaquarterofacircle every 5th day, but no more than 12 timesintotal. A composite anchor was placed on 11 palatally. IPR and PPR were also per- formed according to the lab instruc- tions – distally on the centrals and mesially on the laterals. I was a little too careful at first so more IPR and PPR was needed along the way. Con- sequentappointmentsweremadeat two-weekintervals. Six weeks after treatment began, the upper centrals had moved buccally and the expansion screw no longer required turning. Tooth 11, which had the palatal composite anchor, had over-erupted a little. Following advice from the IAS online support, it reduced in size and moved as far onto the incisal edge as possible to minimise the extrusion force. A sim- ilaranchorwasplacedon21tospread theforceacrossbothteeth.Bothinci- sors were very mobile at that point butthepatientreportednopain. Two weeks later composite anchors were placed buccally on 12 and 22 and a little more PPR was carried out on these teeth distally to encourage rotation. After another fortnight, the anchorswereremovedfromthecen- trals and new ones were placed pala- tally on the laterals. At this point the laterals had both buccal and palatal anchorstoincreaserotation. The IAS online support was once again consulted because not enough rotation of the laterals was being achieved.TheIASInmanAlignerwas senttothelabforabowresetandthe patient had an Essex retainer in the meantime. The IAS Inman Aligner was then used for four more weeks, before treatment was concluded with two IAS Clear Aligners. Bleaching trays were also constructed and bleaching was carried out with Philips Zoom. Finally, the fillings were changed in the anterior teeth and composite build up performed on the centrals, beforeabondedretainerwasfixed. Outcome The patient is very happy with the outcome achieved. The laterals have always bothered her but she was not ready to have fixed orthodontics. She was amazed this result was pos- siblewiththeIASInmanAligner. From my point of view, this was my firstcaseandIfounditverychalleng- ing. It was also not totally without complications – but thanks to pa- tient compliance and fantastic help and feedback from the instructors on the IAS online support, it went really well. I would, however, advise others to begin with an easier case and do not hesitate to contact the in- structorsthroughtheonlinesupport withanyquestions! Figure1.Pre treatment anterior Figure5.Pre treatment upperocclusal Figure10.Post treatment upperanteriors Figure3.Pre treatment right lateral Figure7.Threemonthsinto treatment Figure12.Post treatment left lateral Figure8.Post treatment anterior Figure9.Post treatment retracted Figure9.Post treatment retracted Figure2.Pre treatment retracted Figure6.Twomonthsinto treatment Figure11.Post treatment right lateral Figure4.Pre treatment left lateral Dr.BrynjaBjörk HardardóttirisaGDPfrom Iceland.Shequalifiedas adentist in2003andhas workedatTandvårdsgrup- penBrommainSweden since2012